Can India Solve America’s Health Care Crisis? (For Real!)

The US has always marketed itself as the country that has all the answers, although these days that idea is harder to sell. The US health care system, however, has been in crisis for some time – this is not new. The high cost of healthcare in the US bankrupts households and cripples presidents.

However, India’s health care system is in a similar crisis, with many terrible indicators that we’re all too familiar with. Nevertheless, like lotuses growing tall from a muddy pond, there are many excellent success stories. Will US readers be willing to seek solutions for their health care crisis from India?

Govindarajan and Ramamurti suggest they should indeed do so in “Reverse Innovation in Health Care”. The first part of this book describes a number of innovative social businesses that have developed cost-effective, high quality and profitable models of care delivery such as Aravind Eyecare, Wellspring Maternity Hospitals and Deccan Hospital (all from the south, incidentally).

The main focus is Narayana Health (formally Narayana Hrudalaya) which has 31 hospitals across India and one in the Cayman Islands. By leveraging new technologies, cost efficiencies, task shifting and scale, they are able to perform life-saving surgeries for a fraction of the market rate. The authors suggest these lessons are applicable to America, where hospitals are sluggish, bureaucratic and expensive.

An interesting component of NH’s model is teaching families to conduct post-surgery care through a video tutorial, first in the hospital and then back at home. This is an intervention developed by Noora Health – you can read more about it here. This model reduces anxiety, readmission rates, and post-surgical complications. I am a little bit uncomfortable about this as it seems like this model relies on the fact that women in India often don’t work outside the home, but I suppose you have to leverage the resources you have, and in this case, the resource is low-female workforce participation. I look forward to seeing data about the extent to which this reduces the household economic burden.

The book is by business authors and there is no doubt that by business parameters Narayana Health is a big success (the December 2015 IPO of Narayana Health was oversubscribed 8.6 times). By public health parameters, it’s also a massive success. It has made access to high-quality surgery within reach for millions of people. In addition, the environment is patient-friendly and pleasant (I’ve had a tour of their Boomasandra hospital). The authors are not the only people interested in these Indian models – the former head of the NHS, The Lancet, and the NEJM Catalyst have all promoted them.

The later chapters describe US health entrepreneurs adopting some of these scrappy approaches to strengthen their care delivery settings – proving that the answers to the US’s woes lie in India ;). This was definitely inspiring reading.

My only critique is from a systems perspective. The book recounts how NH & similar models operate a “hub and spoke” model whereby the specialist resources of a tertiary hospital are made accessible to satellite clinics through outreach camps and telemedicine. We have heard of this before and I think it’s all ultapulta– the wrong way around…With the rise in communicable diseases, people are going to need more and more ongoing primary care for disease monitoring and support. At times, they may need surgery, but ideally, surgery would be a discrete event. Their main relationship with allopathic care will be with the primary care doctor. To ensure improved continuity of care and better health outcomes, that would ideally always be the same doctor, who can refer to specialists as required. NSSO data tells us that out of pocket spending is highest around outpatient care (drugs and diagnostics), not inpatient care. So isn’t the primary care centre the hub, and the hospital the spoke? This may seem like semantics, but primary care isn’t given enough policy or business attention (because it’s not so profitable) and this is a problem. We need to stop thinking of primary care as peripheral (or a spoke) and put it in the centre. It needs our attention.

2 Comments

Your bottom-line, “We need to stop thinking of primary care as peripheral (or a spoke) and put it in the centre” is deeply convincing to anyone watching the process and impact of primary health care in the Indian hinterland. We could only wish that decison makers in the higher echelons of Indian public systems grasp it while putting ‘Ayushman Bharat’ in a feasible mould!